Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications — CPB 0606 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0606 governing autologous hematopoietic cell transplantation for autoimmune diseases, effective September 26, 2025. Here's what billing teams need to do.

This update to the Aetna hematopoietic cell transplantation coverage policy tightens the medical necessity criteria for adults with rapidly progressive scleroderma. The change directly affects CPT codes 38206 and 38241 — the autologous harvesting and transplantation codes — along with the broader code set under CPB 0606 in the Aetna system. If your practice or facility bills stem cell transplants for autoimmune indications, this update changes what you need to document before submitting a claim.

Quick-Reference Table

Aetna Hematopoietic Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025

CPB 0606 in the Aetna system now specifies exactly what clinical thresholds a patient must meet before autologous hematopoietic cell transplantation (HCT) qualifies as medically necessary for scleroderma. This is not a blanket approval for systemic sclerosis. The patient must meet specific pulmonary or renal criteria — and must clear a separate set of exclusion criteria — before the coverage policy applies.

Here's the core medical necessity gate. The patient must be an adult aged 18 to 69 with rapidly progressive scleroderma at risk of organ failure. Then they must meet one of two entry criteria:

Meeting one of those two gets the patient into the coverage window. But they also need to clear the exclusion criteria — either by meeting the transplanting institution's selection criteria, or by having none of the following:

The real issue here is the dual-gate structure. A patient can qualify on the lung disease criterion, then get disqualified because their DLCO has deteriorated further below 40%. Your clinical team and transplant coordinators need to check both gates — entry and exclusion — before submitting for prior authorization.

For billing, prior authorization is almost certainly required for CPT 38241 (autologous transplantation) and CPT 38206 (autologous blood-derived HPC harvesting) under this policy. Aetna's coverage policy for transplant procedures routinely requires prior auth. Confirm this with your Aetna provider agreement before the transplant workup begins — not after.

Reimbursement for the full transplant episode depends on clean documentation at each step. That means radiology reports confirming ground-glass opacities, pulmonary function tests with FVC and DLCO values expressed as percent of predicted, creatinine clearance labs, and an echocardiogram showing LVEF of 50% or higher. Missing any one of these is a direct path to claim denial.

Aetna Hematopoietic Cell Transplantation Exclusions and Non-Covered Indications

The HCPCS codes S2140, S2142, and S2150 are explicitly not covered for the indications listed in CPB 0606. These cover cord blood harvesting (S2140), cord blood-derived stem-cell transplantation (S2142), and general bone marrow or blood-derived stem cell harvest/transplant services (S2150).

If your facility bills cord blood transplant services under any of the autoimmune indications covered by CPB 0606, expect denial. These procedures fall outside Aetna's coverage policy for this indication set regardless of clinical rationale. The policy draws a hard line between autologous transplantation using the patient's own cells and cord blood or allogeneic approaches.

Do not attempt to substitute these HCPCS codes for the covered CPT codes. They are structurally different procedures, and Aetna has broken them out separately for a reason.

Coverage Indications at a Glance

Aetna Hematopoietic Cell Transplantation Billing Guidelines and Action Items 2025

The effective date of September 26, 2025 is already in effect. If you're scheduling transplants now for patients with scleroderma, these criteria apply today.

CPT, HCPCS, and ICD-10 Codes for Hematopoietic Cell Transplantation Under CPB 0606

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered HCPCS Codes

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM list under CPB 0606 runs to 221 codes. Below are the codes explicitly present in the policy data. Your billing team should cross-reference the full policy at the source before coding edge cases.

The full ICD-10-CM list includes 221 codes spanning autoimmune, neurological, metabolic, hematologic, and developmental conditions. Pull the complete list from the Aetna CPB 0606 source document before mapping diagnosis codes to claims. Coding to an ICD-10 that doesn't appear on the covered list is a fast path to claim denial with limited appeal options.